| NPI | 1124704895 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: OR 10045770) | 
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: AZ 294125) | 
| Enumeration Date | 2023-06-26 | 
| Last Update Date | 2025-10-13 |